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Methamphetamine Back to Course Index

                             Methamphetamine                                                                 meth

 

 

INTRODUCTION

 

Methamphetamine is a long-acting and very potent drug. It can be ingested in many ways including snorting, swallowing, injecting, or smoking, and it is frequently taken in combination with other drugs. 

 

This course will explore what this drug is, why and how individuals use it and what effect is has on the system.  We will also look at treatment approaches.

 

The Wikipedia, the free encyclopedia, describes methamphetamine as a psycho-stimulant drug used primarily for recreational purposes, but sometimes prescribed for ADHD and narcolepsy under the brand name Desoxyn.  Wikipedia went on to say it causes euphoria and excitement by acting directly on the brain’s reward mechanisms, thus making it highly addictive.  The Merriam Webster’s Medical dictionary defines methamphetamine as an amine C10H15N used in the form of its crystalline hydrochloride as a stimulant for the central nervous system and in the treatment of obesity.

Nora D. Volkow, M.D. Director of NIDA provided insights into methamphetamine through her message to the senate on April 21, 2003:

“The National Institute on Drug Abuse (NIDA) has long recognized the danger of methamphetamine abuse, and has actively supported research on this and related drugs. Understanding methamphetamine’s effects on the brain and behavior is critical to developing both prevention and treatment strategies.

Methamphetamine is a long-acting and very potent stimulant drug. It can be snorted, swallowed, injected, or smoked, and it is frequently taken in combination with other drugs. Like other drugs of abuse, methamphetamine produces a sense of euphoria by increasing the release of dopamine in the brain’s reward centers.

When dopamine is liberated in such high concentrations, it can damage dopamine cells. Indeed, several studies in laboratory animals have corroborated this. In humans, imaging studies have shown that methamphetamine abusers show abnormalities in dopamine function resulting in impairments in movement and cognitive function that are similar, though of a lesser severity, to those seen in patients with Parkinson’s disease. The good news is that unlike Parkinson’s disease, where the damage to the brain cannot be reversed, with protracted abstinence from methamphetamine, there is some return of function. This further highlights the importance of instituting treatment for methamphetamine abusers to maximize their chances of a successful recovery.

There are other dangerous effects of methamphetamine. The large increases in dopamine produced by methamphetamine can trigger psychosis that in some instances persists months after drug use has stopped. Also, because methamphetamine affects the contraction of blood vessels it can result in heart attacks and strokes in relatively young patients.

In addition to its effects on the brain, methamphetamine use is inextricably linked to risky sexual behaviors, thus increasing the risk for transmission of infectious diseases, including HIV. The recent case of a methamphetamine abuser with a particularly virulent strain of HIV is a sobering reminder of this connection. Those who inject the drug risk contracting HIV through the sharing of contaminated equipment, and methamphetamine’s physiological effects may also favor HIV transmission and progression. Preliminary studies suggest that HIV-positive methamphetamine abusers who are on antiretroviral therapy are at greater risk of progressing to AIDS than non-users. Furthermore, interactions between methamphetamine and HIV itself may lead to greater neuronal damage and functional impairment.

Methamphetamine addiction can be treated successfully using currently available behavioral treatments and NIDA is also investing in the development of new medications for methamphetamine addiction. NIDA also is pursuing the development of an immunization strategy based on monoclonal antibodies for the treatment of methamphetamine overdose.”

WHY DO PEOPLE USE METHAMPHETAMINE

 

Many individuals view experimental use of methamphetamine (meth) as harmless and in general, may not be aware of the risks that lie ahead.  For example, when it is first used, the effects can often feel somewhat like a mild stimulant including a sense of euphoria, openness, and intellectual expansion.  There can also be a mild psychedelic component as the new user feels they see the world a little differently.  The sensation of ‘mind-expansion’ and openness quickly fade after the first few uses and physical and mental stimulation dominate the experiential effects.

 

Society may have a different view of why people use meth.  For example, many hold a belief system that all who use are morally weak or that they have criminal tendencies.  It is also a fairly common belief that meth users could stop using if they “really wanted to” and were willing to change their behavior.  These “common beliefs” may be appropriate for early users but have been disproved for individuals who have become addicted to meth. 

 

Researchers have proven that meth has strong addictive characteristics and that most individuals who are addicted lack the ability to overcome their addiction on their own; consequently, many need to change their perceptions and focus on improved treatment modalities to help addicted individuals.  It is abundantly clear from Dr. Volkow’s message that meth use and addiction comprise a public health problem that affects many people and has wide-ranging social consequences.

 

METHAMPHETAMINE Meth1

 

Methamphetamine is similar to amphetamine and cocaine in that they are all classified as psycho-stimulants.  Also, methamphetamine is chemically similar to amphetamine but is quite different from cocaine.  Although these stimulants have similar behavioral and physiological effects, there are some differences in the basic mechanisms of how they work at the level of the nerve cell.  They all result in an accumulation of the neurotransmitter dopamine, and this excessive dopamine concentration appears to produce the stimulation and feelings of euphoria experienced by the user.  It is important to focus on the fact that all drugs impact the brain.  For example, meth enables an excessive amount of dopamine to be liberated that in turn acts upon the pleasure center of the brain and produces a sense of euphoria.  It has also been proven (by studies on laboratory animals) that when dopamine is liberated in high concentrations, it can damage dopamine cells.  In humans, imaging studies have shown that meth abusers develop abnormalities in dopamine function resulting in impairments in movement and cognitive function that are similar, to those seen in patients with Parkinson’s disease.  As noted earlier, researchers have also concluded that with protracted abstinence from meth there is some return of function.

 

When compared to cocaine, meth has a much longer duration of action and a larger percentage of the drug remains unchanged in the body.   Table 1 shows some of the characteristics of meth versus cocaine.

 

                                                Table 1

 

          Methamphetamine                                    Cocaine

 

Synthesized/man-made                            Grown/plant-derived

 

Smoking produces a high that                 Smoking produces a high that lasts 

lasts 8 to 24 hours                                   lasts 20 to 30 minutes

 

Half-life of 12 hours                                  Half-life of one hour

 

Limited medical use                                 May be used as local anesthetic

 

Illicit Methamphetamine comes in a varsity of forms and is generally less expensive than other stimulants.  It is often found as a colorless crystalline solid and sold on the street under the name crystal meth as well as a variety of other names.  It is also sold in less pure crystalline powder called “crank”, or in crystalline rock form or a smokeable form).  It is also sold in pill form and is often mixed with caffeine.  This combination is called “yaba”.  Methamphetamine found on the street is rarely pure.  It typically contains chemicals that were used to synthesize it.  It may be “cut” with non-psychoactive substances like inositol.

 

The more frequently used  “street” names for methamphetamine are:  methamphetamine, meth, speed, ice, crank, tweek/tweak, glass, uppers, yaba, and shabu.  The list of slang names grows significantly when ones from different sections of the US are considered.   

 

 

Meth3HOW IS METH USED?

 

As stated previously, methamphetamine is a synthetic stimulant commonly used as a recreational drug and can be legally prescribed as a treatment for ADHD and obesity under the brand name Desoxyn.  Illicit meth is generally found as an odorless, white or near-white, bitter tasting powder.  It can also be found in pill, capsule and crystal forms.  It can be snorted, taken orally, smoked and/or injected.  As with other psychoactive drugs, different routes of administration have different profiles of effects.  For example, oral ingestion tends to lack rushing, has less euphoric effects and tends to cause far less feelings of wanting to do it again than other methods of administration.  Smoking and injecting are associated with stronger, more euphoric effects and are generally associated with compulsive/addictive user patterns.

 

As with most addictive drugs, the potential for addiction is greater when it is delivered by methods that cause the concentration in the blood to rise quickly, principally because the effects desired by the user are felt more quickly and with a higher intensity than through a moderated delivery mechanism.  Researchers have shown that the subjective pleasure of drug use (the reinforcing component of addiction) is proportional to the rate that the blood level of he drug increases.  In general, smoking is the fastest mechanism followed by injecting, snorting, anal insertion and swallowing.

 

 

Immediately after smoking the drug or injecting it intravenously the user experiences an intense “rush” or “flash” that lasts a few minutes and is described as extremely pleasurable.  Snorting or oral ingestion produces euphoria (a high but not an intense rush).  Snorting produces effects within five minutes and oral ingestion produces effects with twenty minutes.

 

Meth is typically used in a “binge pattern” (to use compulsively or greedily especially as a symptom of drug use) because tolerance to it occurs quickly.  The consequences of this characteristic is that the pleasurable effects fade even before the drug concentration is depleted from the body; consequently, users attempt to maintain the high (pleasurable effects) by continued use of the drug and often in larger amounts.  This pattern will often continue until the user has depleted his or her drug supply and no longer has the financial capability to obtain more drugs.

 

A smokeable form of meth (crystal form) referred to as “ice” became popular in the 1980’s.  Smoking meth actually refers to vaporizing it to produce fumes and inhaling the fumes, rather than burning and inhaling the resulting smoke as with tobacco).  It is commonly smoked in a glass pipe, or in aluminum foil heated by a flame underneath. The smoke/fumes are odorless and produce effects that can continue for ten or more hours.

 

The Drug Enforcement Administration under the Convention of Psychotropic Substances classifies methamphetamine as a Schedule II substance.  Methamphetamine is legally marketed in the United States under the trade name Desoxyn and has several medical uses (ADHD, obesity and others).  Most medical professionals are reluctant to prescribe it due to its notoriety.

 

Methamphetamine is a major focus in the “war on drugs”.  Manufacturing of meth is punishable by mandatory prison sentences in some area of the United States.  In cases where victims are killed due to overdose, the court system has handed out life sentences without possibility of parole.

 


METH USE IN UNITED STATES

 

Monitoring the future Study (MTF) assess the extent of drug use among adolescents and young adults in the United States.  The 2004 findings are:

 

o       Over 6 percent of high school seniors had reported use of methamphetamine at least once during their lifetime.

 

o       Eight graders reported significant decreases in use.

 

Community Epidemiology Work Group (CEWG) data indicates that metamphetamine abuse and production continue at high levels in Hawaii, west coast areas of US and some southwestern areas.  Also, methamphetamine use is continuing to spread eastward. Other items that were reported include:

 

o       Decrease in number of clandestine metamphetamine laboratories

 

o       Increase in substance abuse treatment admissions for methamphetamine

 

o       Some MDMA (ecstasy) and cocaine users are switching to methamphetamine  (thought to be due to lower cost, easier to obtain, and lack of “street awareness” regarding its severe toxicity.)

 

o       Meth is often injected in clubs-placing users and their partners at risk for transmission of HIV, hepatitis C, and other STD’s.

 

The National Survey on Drug Use and Health (NSDUH) indicated over 12 million Americans age 12 and older had tried meth at least once in their lifetime (approximately 5 percent of the population).

 


EFFECTS ON THE BODY meth4

 

Meth is a powerful stimulant and can increase wakefulness, accelerate physical activity and decrease appetite even in small doses.  Meth is also a potent central nervous system stimulant that affects neuro-chemical mechanisms responsible for regulating heart rate, body temperature, blood pressure, appetite, attention, mood and responses associated with alertness or alarm conditions.  Meth use generally increases the heart rate, blood pressure, body temperature, and the rate of breathing of the user.

 

The acute effects of the drug resemble the physiological and psychological effects of an epinephrine-provoked fight-or-flight response, including increased heart rate and blood pressure, vasoconstriction, bronchodilation and hyperglycemia. Users typically report an increase in focus, increased mental alertness and the elimination of fatigue, as well as a decrease in appetite.  Meth also has toxic effects.  In laboratory animals, one high dose has shown to damage nerve terminals in the dopamine-containing regions of the brain.  The large release of dopamine produces by meth is thought to contribute to the drug’s toxic effects on nerve terminals in the brain.  High doses can elevate body temperature to dangerous, sometimes lethal levels, as well as cause convulsions. 

 

The long-term use of meth results in many catastrophic effects, including addiction.  Addiction is a chronic, relapsing disease, characterized by compulsive drug seeking and use, which is accompanied by functional and molecular changes in the brain.  Chronic methamphetamine abusers exhibit symptoms that can include violent behavior, anxiety, confusion and insomnia.  They can also display a number of psychotic features, including paranoia, auditory hallucination, mood disturbances, and delusions (for example, the sensation of insects crawling on the skin).  The paranoia can result in homicidal, as well as suicidal ideation.

 

With chronic use of meth, the body develops a tolerance to the drug rather quickly; consequently, users may take higher doses of the drug, take it more frequently or change their method of intake in order to obtain the desired effects. In some cases, users forego food and sleep while indulging in a form of binging known as a “run”, injecting up to a gram of the drug every few hours over several days until the user runs out of the drug or is too disorganized to continue.  Chronic use can lead to psychotic behavior, characterized by intense paranoia, visual and auditory hallucination, and out-of-control rages that can be coupled with extremely violent behavior. Table 2 summarized the short and long term effects of meth use.

 

                                      TABLE 2

 

Short-term effects can include:      Long-term effects can include:

 

Increased:                                        Dependence/addiction

          Attention                                 Paranoia hallucinations

          Activity/aggression                Mood disturbances               

          Respiration                            Repetitive motor activity        

          Anxiety                                   Aggression                  

Decreased:                                     Stroke

          Fatigue                                   Weight loss

          Appetite                                 Health problems (malnutrition, teeth)

Euphoria and rush                          

Hypothermia

 

There are no physical manifestations of a withdrawal syndrome when meth use is stopped; however, there are several symptoms that occur when a chronic user stops taking the drug.  The salient ones are depression, anxiety, fatigue (excessive sleep), paranoia, aggression, and an intense craving for the drug.

 

SIDE EFFECTS

 

The side effects of meth use include jitteriness, repetitive behavior (tweaking) and jaw clenching or teeth grinding.  Also, meth users may experience dental problems as they may loose their teeth abnormally fast, a condition known as “meth mouth”.  This appears to be caused in that methamphetamine causes decreased production of acid-fighting saliva and increased thirst, resulting in increased risk for tooth decay, especially when high-sugar drinks quench thirst.

 

Users may exhibit compulsive (out-of-control) sexual behavior and may engage in-group sexual acts; consequently, this leads to increased transmission of sexual transmitted disease (STD’s), especially HIV and syphilis.   Common side effects associated with regular use are:

 

o       Nausea, loss of appetite, insomnia

o       Diarrhea, tremor, jaw-clenching

o       Agitation, compulsive fascination with repetitive tasks (Punding)

o       Irritability, panic attacks, talkative

o       Increased libido

o       Dilated pupils

 

The common side effects associated with chronic meth use are:

 

o       Drug craving

o       Weight loss

o       Depression

o       Erectile dysfunction

o       Excessive tooth decay

o       Psychosis

 

The common side effects associated with overdose are:

 

o       Formication (feels like bugs are crawling on skin; may include compulsive picking and infecting sores “meth mites”)

o       Brain damage

o       Delusions, hallucinations, paranoia

o       Sweats

o       Hypothermia

o       Kidney damage

 

Most overdose fatalities are due to stroke or heart failure but can also be caused by hypothermia or kidney failure.  Overdose on meth is a serious medical situation; consequently, the individual should be under the care of a physician.

 

 meth5ADDICTION PROCESS

 

Researchers have proven that drugs alter normal brain functioning; thereby, creating powerful feelings of pleasure.  Where there is pleasure there is generally repeated behaviors.  Consequently, as we repeat this process over time our brain becomes dependent on the drug and needs it to feel normal.  Also, as we develop tolerance to the drug it takes more and more of the drug to reach the previous level of pleasure.  When an individual progresses to this stage he or she suffers from a compulsive drug craving and thereby usage and generally cannot quit by him or herself.  Treatment is necessary to end this compulsive behavior. 

 

 

DRUG-RELATED DISORDERS

 

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) includes a description for a class of amphetamine-like substances and includes all substances with a substituted-phenyuletamine structure, such as amphetamine, dextroamphetamine, and methamphetamine (“speed”).  Also included are those substances that are structurally different but also have amphetamine-like action, such as methylphenidate or agents used as appetite suppressants (“diet pills”).  The following excerpts were taken from the DSM-IV.

 

Meth Dependence:

 

The patterns of use and course of dependence are similar to those of cocaine dependence because both substances are potent central nervous system stimulants with similar psychoactive and sympathomimetic effects.  However, methamphetamine is longer acting than cocaine and thus is usually self-administered fewer times per day.  As with cocaine dependence, usage may be chronic or episodic, with binges (“speed runs”) punctuated by brief drug-free periods.  Aggressive or violent behavior is associated with methamphetamine dependence, especially when high doses are smoked, ingested or administered intravenously.  Intense, but temporary anxiety resembling Panic Disorders or Generalized Anxiety Disorders, as well as paranoid ideation and psychotic episodes that resemble schizophrenia, Paranoid Type are often seen, especially in association with high-dose use. Withdrawal states are often associated with temporary, but potentially intense, depressive symptoms that can resemble a Major Depressive Episode.  Tolerance to methamphetamine develops and often leads to substantial escalation of the dose.  Conversely, some individuals with Methamphetamine Dependence develop sensitization, which is characterized by enhanced augmentation of an effect following repeated exposure.  In these cases, small doses may produce marked stimulation and other adverse mental and neurological effects.

 

Meth Abuse

 

Even individuals whose pattern of use does not meet criteria for Dependence can develop multiple problems with meth.  Legal difficulties typically arise as a result of behavior while intoxicated with meth (especially aggressive behavior), as a consequence of obtaining the drug on the illegal market, or as a result of drug possession or use.  Occasionally, individuals with meth abuse will engage in illegal acts (e.g., manufacturing meth, theft) to obtain the drug; however, this behavior is more common among those with Dependence.  Individuals may continue to use the substance regardless of the consequence of continued use frequently resulting in arguments with family members or presents a negative example to children or other close family members.  When these problems are accompanied by evidence of tolerance, withdrawal, or compulsive behavior a diagnosis of Dependence rather than Abuse should be considered.   However, since some symptoms of tolerance, withdrawal, or compulsive use can occur in individuals with Abuse but not Dependence, it is important to determine whether the full criteria for Dependence are met.

 

Criteria for Diagnosis:

 

The DSM-IV presents the following criteria for a diagnosis of Substance Dependence:

 

The essential feature of Substance Dependence is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems.  In essence, it is a pattern of repeated self-administration that can result in tolerance, withdrawal, and compulsive drug-taking behavior.  The criteria for substance dependence is a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

(1)             tolerance, as defined by either of the following:

(a)             a need for markedly increased amounts of the substance to

achieve intoxication or desired effect

(b)             markedly diminished effect with continued use of the same amount of the substance

(2)             withdrawal as manifested by either of the following:

(a)     the characteristics withdrawal syndrome for the substance (b)   the same (or a closely related) substance is taken to relieve

          or avoid withdrawal symptoms

(3)             the substance is often taken in larger amounts or over a longer period than was intended

(4)             there is a persistent desire or unsuccessful efforts to cut down or control substance use

(5)             a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects

(6)             important social, occupational, or recreational activities are given up or reduced because of substance use

(7)             the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by substance use (e.g., current marijuana use despite recognition of marijuana-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

           

The DSM-IV presents the following criteria for a diagnosis of Substance Abuse:

 

The essential feature of Substance Abuse is a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of the substance.  In order of an abuse criterion to be met, the substance-related problem must have occurred repeatedly during the same 12-month period or been persistent. There may be repeated failure to fulfill major role obligations, repeated use in situations in which it is physically hazardous, multiple legal problems, and recurrent social and interpersonal problems.  Unlike the criteria for Substance Dependence, the criteria for Substance Abuse do not include tolerance, withdrawal, or a pattern of compulsive use and instead include only the harmful consequences of repeated used. 

 

The criteria for a Substance Abuse is:

A.   a maladaptive pattern or substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

(1)     recurrent substance use resulting in a failure to fulfill major role obligations at  work, school or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)

(2) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)

(3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)

(4)  continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences or intoxication, physical fights)

 

B.   The symptoms have never met the criteria for substance Dependence

for this class of substance.

 

THE ESSENCE OF ADDICTION

 

Scientific research and clinical experience has shown that drug craving and the related compulsive behaviors are the “essence of addiction”.  They are extremely difficult to control, much more difficult than physical dependence.  For an addict, there is no motivation more powerful than drug craving; consequently, we need to focus on addiction as “compulsive, uncontrollable drug seeking and use even in the face of negative health and social consequences. Therefore, focusing on addiction in this manner should help clarify everyone’s perception of the nature of addiction and of potentially addicting drugs.  For the addict and the clinician, this more accurate definition forces the focus of treatment away from simply managing physical withdrawal symptoms and toward dealing with the more meaningful, and powerful, concept of uncontrollable drug seeking use.  Consequently, the focus of all treatment programs should be to help the addict to regain control over these behaviors.

 

The approach from modern science is that in deciding which drugs are addicting and require what kind of societal attention (war on drugs), we should focus primarily on whether taking them causes uncontrollable drug seeking and use.  One important example is the use of opiates, like morphine to treat cancer pain.  In most circumstances, opiates are addicting.  However, when administered for pain, although morphine treatment can produce physical dependence – which now can be managed after stopping use – it typically does not cause compulsive, uncontrollable morphine seeking and use, addiction as defined here.  This is why so many cancer physicians find it acceptable to prescribe opiates for cancer pain.

It is important to emphasize that meth addiction, can be treated, both behaviorally and, in some cases, with medications, but it is not simple.  We have a range of effective addiction treatments in our clinical toolbox although admittedly not enough.  This is why we continue to invest in research, to improve existing treatments and to develop new approaches to help people deal with their compulsive drug use.

 

Our national attitudes and the ways we deal with addiction and addicting drugs should follow the science and reflect the new, modern understanding of what matters in addiction.  We certainly will do a better job of serving everyone affected by addiction – addicts, their families and their communities – if we focus on what really matters to them.  As a society, the success of our efforts to deal with the drug problem depends on an accurate understanding of the problem.

 

ADDICTION PROCESS

 

The addiction process is presented to help the clinician and the drug user to better understand “ the why” behind their use and abuse of drugs.  The hope is that the better this process is understood, the more effective counseling and other treatment modalities can be toward helping the user to achieve a drug-free life.  It is imperative that clinicians in the field of addictions understand the cognitive, behavioral and physical aspects of drug use.  The objectives are for the clinician involved with treatment to recognize the special needs of this sub-population and design treatment modalities aimed at their specific needs.  For example, as it is beneficial for an insulin dependent diabetic to be educated on all aspects of diabetes, it is equally important for an individual who abuses methamphetamine to be educated on all aspects of meth use including impulse control, distorted cognitive ability and the consequences of poor decision-making.

  

Figure 1 depicts a typical addiction process and identifies the major functional blocks of the process.  The essence of this process is that if an individual has a flawed or permissive value/belief system (based upon his or her perceptions of events, teachings and influences of his family, friends, peers and other during his or her early life) it leads to that individual having a distorted cognitive ability.  That, in turn, enables an individual to continue to use and will ultimately result in unmanageability of his or her life (if the cycle is not disrupted).  The following paragraphs describe each block and how it impacts the user’s life.

 

 Mar1

 

Value/Belief System

 

An individual’s value/belief system reflects his/her perception of self and represents values, judgments and myths that he/she believes to be true.  A persons value/belief system is fairly well established at an early age and is refined and honed as life’s experiences make us into the person we are at any given time in our life.   It is the major control and decision-making guide and helps us to chose between right and wrong and “things we do” versus “things we don’t do”.  Most individuals have a value/belief system about:

 

·              Religion/race

·              Alcohol and other drugs use/abuse

·              Sexuality

·              Education/career

·              Peer pressure/social acceptance/social involvement

·              Honesty, fair play, generosity

·              Family roles/authority

 

A clinician should explore a client’s value/belief system to better understand what they believe about various topics including topics related to drug use.  An important area to explore is the environment they were exposed to during their early life.  For example, did their parents or caregivers have a permissive attitude toward drugs?  Were drugs readily available in or near their and what was the norm regarding use of alcohol and other drugs?

 

Other questions might include:

 

·              Were you exposed to limits or restrictions as a youth?

·              Did your parents use drugs?

·               Were you allowed to drink, smoke or use drugs with your parents?

·              At what age did you start to drink or smoke?

·              Was there a permissive attitude (toward drug used) in your home/neighborhood?

·               Did you have a detailed schedule as a youth?

·              Did your parents involve themselves with your friends?

·              Did your parents monitor your activities?

 

 

This is an attempt to assess the risk factors the individual was exposed to during his or her early life.  Generally, a permissive attitude/environment will provide early opportunities to experiment with alcohol, tobacco and other drugs.  This liberal, permissive environment also enables a young person to form a positive image of most activities and/or to establish a distorted mental picture of specific activity (such as use of alcohol and other drugs).   To give an example of how our belief/values work in the life of a meth user, let’s suppose a person forms a concept of a problem user as one who is unemployed and has an arrest record.  Now, let’s suppose this individual is a compulsive user but does not meet his or her pre-programmed characteristics of how they perceive an addict to be or act.  In this case, the individual would test his situation against his value/belief system and would conclude he or she does not have a drug problem.  The cycle is repeated until there is a match between his/her behavior and his/her pre-programmed belief/value system about drug use.  It should also be noted that an individual’s belief system about drug use might change in response to his or her own experiences and influences from clinicians and other treatment modalities.  The cycle may also be disrupted by other factors (generally a crisis) in the user’s life.

 

Distorted Cognitive Ability

 

A flawed or permissive value/belief system results in a distorted cognitive ability that, in turn, results in illogical and impaired thinking; consequently, the affected individual continues to make high-risk decisions for themselves.  With respect to use of drugs, it results in compulsive, uncontrolled drug craving, seeking and use.  It follows that an individual is unable to comprehend the reality, consequences or truth about events/actions/activities.  When an individual cannot see the reality or truth about things, the distorted cognitive activity is generally referred to as denial.  The most common forms of denial are:

 

·              Rationalizing: Making excuses for drug use.  Example,  “all of my friends use more than me”.

 

·              Minimizing: Indicating his/her use is less serious than it really is.  Example: “Sure I use”, but not that much”; “I only use on week ends, real users use every day”.

 

·              Blaming: I use meth because;  “all of my friends do”.  The user admits involvement but the responsibility for it lies with someone else.

 

An important challenge facing most compulsive users it to break through denial and accept the reality of their situation; The greatest challenge in the counseling situation is to help the individual through this process.  This generally takes patience, professionalism, research, and a willingness to face adversity. The client must adjust to a changing lifestyle and adapt new coping strategies and new ways to divert himself or herself away from his or her former lifestyle.   Learning new concepts is usually met with résistance, as most individuals don’t want to change and will only change in response to pain or another strong motivator.   Distorted cognitive activity or impaired thoughts mask the reality of most situations, and truth (in many cases) ceases to exist.  A meth user who finds himself in a quagmire can gain insight as to their preconception (thinking) regarding excessive use by answering and analyzing the following questions:

 

·              Most frequently used form of denial (with respect to meth use) is: __________ (rationalizing, minimizing, blaming or others).

·              Most frequently processed impaired thought:  ____________________________________________

·              I’m not a problem user because: ____________________________________________

 

If an individual becomes emotionally stressed when asked these types of questions, it is a strong indication that the individual is in denial regarding their involvement with drugs and they are in need of professional help. The key to any cognitive change is that the individual be open and honest and willing to accept that change is needed.  If they have a good attitude, it is easier for them to accept the perils associated with compulsive use.  The net is that people can change but in most cases the change must be initiated at the cognitive level.  If one is in denial regarding a problem there is very little that anyone else can do to help that individual.

 

Cycle Of Use

 

The “cycle of use” is an outcome of an individual continuing to live with distorted cognitive functioning. This on-going activity results in addiction (again, compulsive, uncontrolled drug craving, seeking and use).  This lifestyle is problematic and typically follows a well-established pattern.  At this phase of use, his or her “drug related choices” begins to disrupt normal activities with family, work, school and social and community.  His or her use is increasing in importance to where it is masking most other activity/relationships.  It generally results in behavioral problems or unmanageability of one’s life.

 

Unmanageability

 

As the use continues, the individual begins to encounter the negative consequences of his/her behavior.  In general, the consequences cause pain (psychological or physiological) that, when severe enough, may increase his or her willingness to accept help.  The hypothesis is that deeply imbedded in human nature is the tendency to resist all change until we finally experience pain and then we may stop to look at the cause of the pain.  This process may manifest itself in any of the following:

·          Physical (health problems, increased risk taking, aggression)

·          Social problems (family, work, school, community)

·          Emotional (feelings of guilt, shame or depression)

·          Spiritual (low self-esteem, feeling empty, isolated)

·          Financial (heavy debt load; inability to manage)

·          Job loss

 

Another self-analysis assignment is for an individual to identify the negative consequences as a result of his/her meth use.  This exercise is generally done over several counseling sessions and ultimately will lead the individual to accept responsibility for their decisions (related to drug use). 

 

 

INDIVIDUAL ADDICTION CYCLE

 

Figure 2 depicts an individual addiction cycle for a meth user and identifies the major blocks associated with the cycle.   Most clinicians believe that all addictions fit into a cycle and that it starts with a cognitive process related to the event (thinking about or preoccupation with the activity).

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Preoccupation

 

Preoccupy is defined as “to absorb wholly the mind or attention of” or “ occupy beforehand or before another”. It can be viewed as a ‘locked in’ mind state, where the main focus is on obtaining his or her drug of choice.  Some individuals are so focused they appear to be in a somnolent state (as of deep hypnosis) where the individual may have limited sensory and motor contact with his or her surroundings and subsequent lack of recall. Most somnolent states vary in intensity, duration and frequency.  The initial onset may be mild but generally get more intense as time passes without satisfying the impulse.   The intensity of the state also varies depending on how long the individual has been a drug user, as all individuals are creatures of habit and we program ourselves to expect resolution within a predetermined timeframe or the mind will increase the desire to satisfy the impulse.   An approach to understanding this phase of use is to ask the user a series of questions such as:

 

·          What thoughts did you focus on when you initially began to use meth?

·          Was your intent (reason for use) to overcome fatigue, increase alertness or control appetite? 

·          Did you use due to social pressure or the influence of friends?

·          How did your attitude toward drugs change as the compulsion to use increased?

·          What are your thoughts like at present?

·          What do you think regarding using again?

 

 

Remember that it takes time to break old habits and to re-program our minds to desire different things.   Also, remember the urge to continue to use will be very strong when an individual initially stops.  It’s also safe to say that “everyone thinks about resuming use”, and individuals must be resilient in their efforts to break the cycle.  This exercise is intended as a tool that will help the individual to become familiar with how his/her mind works and the thought processes prior to previous relapses.   Again, the mind wants to continue to do those things that bring pleasure.  A “drug binge”, “big shopping spree” or  “hanging out with former using buddies“ can be positive events in the mind and individuals want to repeat them, as such.  Consequently, there is a strong drive to set aside or dismiss concepts that would limit doing what we want to do.  I have often stated in-group sessions that using is an extremely selfish action.  It basically says, “I will do what I want to do without any thought for health, family or other considerations.”  Unfortunately, we all know there is the negative side to compulsive use, but our mind is quick to “set aside” those thoughts when the other thoughts are being processed. As healthy, normal humans, it is always a good idea to keep the rewards versus consequences balanced in our minds.  I often use the phrase, ‘when one makes the decision (for example, to use drugs) they also accept the consequences”.  Sometimes good (pleasure) happens, but most of the time bad and sometimes catastrophic events can occur.

 

Habits/Ritual

 

The second part of the individualized addiction cycle is a set of habits that typically lead to drug use.  Some counselors may refer to this as ritualistic behavior or as a person being on autopilot where the behavior is almost fully automatic and, once initiated, the activities are generally done without thinking.  The preceding cycle (Figure 1) discusses preoccupation, which is thought without action (it may lead to action), whereas this cycle addresses a set of habits (ritual) that are typically completed without thought.

 

A using ritual is the behavior that leads to use.  For example, it may be as simple as an urge to get together with old friends (former using buddies) or thinking about an event that previously include drug use (concert).  It may also be triggered by an argument with a spouse; loss of a job or other catastrophic events or it could be as insignificant as driving through a neighborhood where his or her former supplier lived.  In any event, it is “something” that triggers a thought in our minds that initiates a chain of events that leads to using.  This is another view of compulsivity.  It’s also important to note that when a ritual is initiated, it is very difficult to stop the process.  For a compulsive drug user, it is virtually impossible without professional help.

 

Another assignment for the addicted individual is to describe what keys their use. List and analyze the activities and behaviors leading to use.  The objective is that the better we understand what motivates an individual; the easier it is to interrupt the cycle.  The second part of the exercise is to identify what could be done to disrupt the process.   This may be as simple as planning an evening of entertainment at home with the family.  Whatever the case may be, the better one understands themselves, the easier it is to manage their lives and to make better decisions.

 

Compulsivity

 

The third block of Figure 2 is compulsivity.  Compulsive actions are related to an irresistible impulse to perform an irrational act.  In essence, the user has an impulse control problem and/or is susceptible to relapse. Consequently, compulsivity is characterized as continued use of the substance despite significant substance-related problems.  Some clinicians refer to this phase as “when the user begins to experience the “consequences of his use”.  Also, most users are aware of their need to stop using and have made several unsuccessful attempts to stop.  This tendency leads to a look at relapse where the clinician and user attempt to identify what triggered the action (resumption of use) and how he or she may avoid that activity in the future.  The clinician must always be mindful that when the user resumes use, he or she expects to experience euphoria.  Unfortunately, the opposite emotions, of fear, hopelessness and helplessness, shame, guilt, depression and despair are often encountered.  One must remember that our minds retain the positive memorizes and have a tendency to set aside the negative ones.   Therefore, the individual ‘thinks’ he/she will experience a high, when, in fact, he/she has been deceived by his/her own mind.  An onset trigger for depression is when the individual is expecting an unrealistic outcome and finally realizes he/she has to deal with a set of negative consequences.

 

Despair

 

Despair is the end result of addiction and is where feelings of hopelessness abound.  This block represents the consequences of compulsive use (negative impact on family, work, society, health) and the user generally has feelings of shame and guilt following episodes of use.   However, the addicted individual’s mind attempts to soften his/her despair by processing thoughts such as “I will never use again”; “things will be different in the future”.  The effect of this mental defense mechanism is to alleviate the bad feeling as quickly as possible by processing the neutralizing thoughts.  So, instead of facing the addiction, the individual’s mind has found another way to deny the addiction; consequently, the cycle continues.

   


PREVENTION/TREATMENT

 

Meth abuse and addiction is a complex problem involving biological changes in the brain as well as a myriad of social, familial and environmental factors; consequently, the treatment challenge is more demanding for meth than most other drugs; consequently, treatment strategies need to assess the psychobiological, social, and pharmacological aspects of the patent’s drug abuse.  Also, there was an increase in the number of people seeking treatment in the United States.  Treatment providers in most areas of the country report that meth is increasing and that some former cocaine addicts are now switching to meth.  The majority of individuals seeking treatment smoke crack, and are likely to be polydrug users, or users of more than one substance.   

 

Pharmacological Approaches

 

There are currently no particular pharmacological treatments for dependence on amphetamine or amphetamine-like drugs such as methamphetamine.  The current approach is borrowed from experience with treatment of cocaine dependence.  Unfortunately, there is no single agent that has proven efficacious to combat cocaine addiction.  Antidepressant medications are helpful in combating the depressive symptoms frequently seen in meth users who recently have become abstinent.

 

NIDA is continuing to invest in the development of new medications for meth addiction.  Although some medications appear promising (and may help some time in the future) it is safe to say that a “silver bullet” to stop meth abuse is yet to be found.  NIDA is also investing in the development of an immunization strategy based on monoclonal antibodies for the treatment meth overdose.

 

 

Behavioral Interventions

 

Currently, the most effective treatment for meth addiction is Cognitive Behavioral Therapy (CBT).  CBT is a form of psychotherapy that emphasizes the importance role of thinking in how we feel and what we do.  CBT therapists teach that when our brains are healthy, it is our thinking that causes us to feel and act the way we do.  It is designed to help modify or change the addict’s thinking, expectancies, and behaviors and to increase skills in coping with various life stressors.  This approach shows promising results for meth addicts when coupled with other programs such as self-help programs (meth anonymous).   The evidence supporting the need of a dual treatment approach surfaced in a study in a clinic at the San Francisco Veterans Affairs Medial Center (VAMC), where investigators at the University of California, San Francisco (UCSF), compared the efficacy of CBT with 12-step facilitation (12SF). (Barbara Shine, NIDA Notes).  CBT theory holds that our surroundings strongly influence our thinking and behavior, so CBT introduces their patients to new ways of acting and thinking in response to their environment.  CBT is based on the scientifically supported assumption that most emotional and behavioral reactions are learned.  Therefore, the goal of therapy is to help the client unlearn their unwanted reactions and to learn a new way of reacting and doing.  A central aspect of rational thinking is that it is based on fact not simply on our assumptions made.  Often we upset ourselves about things when, in fact, the situation isn’t like we think it is.  Therefore, the inductive method encourages us to look at our thoughts as being hypotheses that can be questioned and tested.  If we fin that our hypotheses are incorrect (because w3e have new information), then we can change our thinking to be in line with how the situation really is.

 

In order to increase the overall effectiveness of meth treatment, it has been found that a dual approach of CBT plus a 12-step recovery program has helped many meth addicts to achieve long-term abstinence.  These self-help programs have limited statistically measurable effects, as they do not release any quantifiable measure of its success rates.  There are, however many recovering addicts who claim these programs have aided them.  They provide a type of fellowship and mutual support through regular group meetings as a path toward recovery from addiction.  The 12-step program is not affiliated with any religious group, however there is a spiritual component-belief in a “power greater than one’s self” of some kind that helps members achieve and maintain abstinence.

 


RELAPSE PREVENTION

 

Probably the greatest challenge facing recovering meth addicts (and the substance abuse counselors who work with the clients) is to avoid relapse.  This CEU will present a prevention technique developed by Marlott and Gordon in 1995.  They described a comprehensive relapse prevention technique for alcohol and other drug addicts.  This treatment application will also help a meth addict regain control of their life.   They suggested an approach where high-risk situations were assessed and then coping strategies were developed for each situation.  The following factors were analyzed for each situation:

 

·          Self-Efficacy: The individual’s perception of his/her ability to cope with situations.

·          Expectations:  What is the consequence to the user of a specific behavior?

·          Attribute:  Why an individual exhibits a specific behavior.

·          Decision-Making:  Methodology used when the individual chooses a specific action.

 

Once this analysis is complete, Marlatt and Gordon suggest the following intervention strategies:

 

·          Self-monitoring: Maintaining a log of urges/needs to use meth.  Additional information such as intensity of urge and coping strategy employed may also be documented.

 

·          Direct observation: The individual rates the degree of temptation due to various situations.  The individual may respond to an imaginary past episode or a fantasy about a past episode and then describe what he/she may have done differently to avoid future encounters.

 

·          Coping Skills: This analytical tool is used to document the client’s ability to cope once a high-risk behavior is encountered.  This helps the individual to identify strengths and weaknesses and helps the client focus on areas that need improvement.

 

·          Decision Matrix:  The matrix is used to document the consequences of a specific decision or action.  It may be used to gather immediate, as well as delayed consequences and can document both positive and negative outcomes.

 

·          Behavioral Commitment: This tool is intended to establish limits on drug use (if any).  It is also a commitment to seek help at the first episode of use, to prevent a full-scale return to using.

 

·          Reminder Questions: They are used to key specific avoidance actions in the event of a strong urge.

 

It follows that a primary goal of any prevention program is to enable the individual to cope with future, inevitable urges to use meth.  The initial step is to identify the coping strategies that can be used in high-risk situations.  It is also important to discuss an implementation plans for how these skills will be used.  Some have referred to this process as setting up a self-management program.  According to Ricky George (1990), “ The goals of self-management programs are to teach the individual how to anticipate and cope with the problem of relapse.”  This approach generally combines behavioral skills training, cognitive interventions and lifestyle changes to help the individual modify their behavior.

 

 

RECOVERY MODEL

 

This model is based on the concept that recovery is a process that requires the mastery of emotional, psychological, and social and recovery related tasks.  These tasks, which become increasingly more challenging, are the foundation for recovery.  Recovery is defined as the ongoing process of improving one’s level of functioning while striving to remain drug-free.  A brief overview of a recovery process follows:

 

·          Pre-treatment phase:       

    The individual experiences or becomes aware of:

o       Unpleasant consequences associated with drug use (family problems, loss of friends, loss of job, loss of freedom, financial problems);

o        Loss of control of their life; and emotional pain (may motivate individual to decide to enter treatment).

 

·           Initial stabilization:

o        Stop use of meth; avoid former using situations and “buddies”;

o        Professionally managed coping and emotional strategies (to ease the discontent associated with urges to resume using);

o        Help with controlling impulsive behavior (counseling)

 

Phase 1:    Recovery (Getting Started)

 

·          Helps individual to accept and comprehend the addiction process

·          Identify use triggers:  Develop a plan to avoid and control impulses.

·          Learn problem solving, stress management, and anger management skills.

·          Accept personal responsibility for self (choices, decisions, behaviors, and consequences);

·          Express feelings. 

 

Phase 2:    Recovery (Early)

 

·          Accepts need for recovery

·          Accepts responsibility for management of meth use

·          Begins to develop a drug-free self-image

·          Acknowledges the need for lifestyle changes; new friends

·          Adjusts to non-use behavior – apply new problem solving skills as needed

·          May struggle with peer and family issues as drug-free lifestyle is demonstrated

·          Improved self-image.

 

Phase 3 (Middle)

·          Changed behavior and cognitive awareness aligned with new self-concept.

·          Accepts responsibility for own recovery.

·          Recognizes and embraces success of recovery.

·          Incorporates problem-solving skills into new lifestyle.

·          Comfortable with lifestyle changes.

·          Continues to struggle with peer and family issues.

·          Learns to balance and control life.

 

Phase 4 (Advanced)

 

·          Focus on learning coping skills to help deal with peers and family

·          Increases scope of life; starts to fulfill potential.

·          Develops balance and takes control of life.

·          Develops independence from the treatment program – develops self-initiative.

·          Accepts identity as a recovering individual.

 

After Care

 

·          Positive experiences fuel personal growth.

·          Focus on total person (activities, spiritual growth and independence).

 

Keys to Avoid A Return to Problematic meth use:

 

·          High Activity Level: An idle mind often wanders in the wrong direction.

·          Generate “To Do” lists to guide daily activities.

·          Goal setting to acknowledge and reward success.

·          Individual reward system: Work toward a specific individualized reward.  For example, new car, trip, clothes.

·          Plan pleasurable activities:        Hobbies, travel, reading, etc.

·          Plan self-improvement activities: Items that will help the individual feel good about themselves.

o       Exercise/ active lifestyle

o       Nutrition program

o       Rest/relaxation time

o       Manage stress

·          Think positive.

·          Avoidance of high risk situations and activities

o       Events that previously led to use;

o       Avoid people/functions whose focus is on drug use.

·          Avoid ‘things’ that have triggered previous relapses.

·          Develop mind-management techniques:     Block negative thought processes.  The mind always leads the physical act (i.e., an individual thinks positive regarding an activity before they do the activity).  Consequently, if we could train our minds to detect ‘wrong’ thinking (about drug use), then we could alter or disrupt those thoughts and focus on different things or thought processes to avoid actually using.

·          Avoid over confident feelings, such as, “I am in control and I have this problem licked”.  Generally, overconfidence leads to high-risk behavior and poor decision-making.

·          Avoid out-of-balance emotional states.  Either feeling too good (overconfident) or too bad (depression) can lead to resumption of use.

·          Forgetting or rationalizing away the pain and anguish of the former lifestyle.  Our minds will sometimes focus only on the pleasurable aspects of a former activity and completely mask (or forget) the negative consequences.  At times, individuals are convinced that returning to a former lifestyle would be wonderful (feeling, euphoria, emotions, etc.)  However, when they actually return to that lifestyle, they become deeply depressed as the reality (negative consequences) of their actual use is realized.  The mind is a wonderful thing, but it too must be monitored and trained and one must realize that the mind can be misleading in some cases.

·          Think positive; act positive, surround yourself with positive people.   Remember the little engine that said, “I think I can”.